Sunday, April 22, 2012

Getting Over Therapy

As the old saying goes, better late than never….

Four or so years ago I started a new blog called “Had Enough Therapy?” I meant the blog as a complement to my website. There I explained, in detail, the difference between introspective psychotherapy and life coaching.

Imagine my surprise and my pleasure when I saw that the New York Times had finally caught on. Or, at least, therapist Jonathan Alpert, writing in the Times this morning, has.

Alpert’s op-ed is entitled: “Is Therapy Forever? Enough Already.” To my admittedly biased mind, it sounds like a take-off on the title of this blog.

As concepts go, it isn’t quite as good, but “Had Enough Therapy?” was already taken.

I am confident that Alpert does not read this blog. If he had I’m sure he would have mentioned it. So let’s say that he has come to the same conclusion, independently.

Of course, what Alpert calls “aggressive therapy” I call coaching. Be that as it may, let’s examine his point of view:

Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans. They don’t need to talk endlessly about how they feel or about childhood memories. A recent study by the National Institute for Health and Welfare in Finland found that “active, engaging and extroverted therapists” helped patients more quickly in the short term than “cautious, nonintrusive therapists.”

Opinion, advice, and a structured action plan… sounds like coaching to me.

In truth it doesn’t matter so much what we call it. Alpert is right that most people do not need to spend years talking about how they feel or exploring their childhood memories. Not only is it a waste of time; it avoids the problem at hand.

Alpert is also right in his characterization of therapy. Even though the field is hopefully moving toward a cognitive-behavioral approach, still, when people think of therapy they think of getting in touch with their feelings, and rediscovering their lost past.

Alpert offers us an excellent clinical vignette:

If a patient comes to me and tells me she’s been unhappy with her boyfriend for the past year, I don’t ask, as some might, “How do you feel about that?” I already know how she feels about that. She just told me. She’s unhappy. When she asks me what I think she should do, I don’t respond with a return interrogatory, “What do you think you should do?” If she knew, she wouldn’t ask me for my thoughts.

Of course, once we raise questions about what people should do, we are dealing with issues that are properly within the domain of ethics.

Alpert continues:

Instead I ask what might be missing from her relationship and sketch out possible ways to fill in relationship gaps or, perhaps, to end it in a healthy way. Rather than dwell on the past and hash out stories from childhood, I encourage patients to find the courage to confront an adversary, take risks and embrace change. My aim is to give patients the skills needed to confront their fear of change, rather than to nod my head and ask how they feel.

The truth is, if he had encouraged her to hash out stories from childhood he would have been telling her that her relationship does not need active management, thus, that she need do nothing about it.

He would have been telling her what far too many therapists have been telling far too many patients for far too long: that the problem is all in her mind, and that if she rearranges her mental furniture then her relationship will magically improve.

I would only add one observation here. The culture being what it is, many patients who consult with therapists bring with them an expectation that they will while away their therapy sessions exploring their feelings and rehashing their childhood memories.

Hopefully, Alpert’s column will help change patient expectations.  After all, you can give the best advice or set up the best action plan, but if your patients have been taught that anyone who gives them advice is insulting them, you are going to have your work cut out for you.


JP said...

Many of my client are in therapy because of chronic pain, generally multiple back surgeries or some surgery gone wrong, which results in chronic depression/anxiety.

The pain isn't going anywhere, so neither is the therapy. Of course, either are the pain meds, which is a whole other problem.

There isn't really a solution for the pain, so ongoing professional emotional support seems fine in that situation.

Stuart Schneiderman said...

The problem with these kinds of discussions is that there are many different kinds of therapy.

Alpert distinguishes well enough between the kind of therapy that wants to rehash the past and the kind that wants to make plans for dealing with the future.

About that I agree.

Yet, many patients are also helped when they can find a therapist with whom they can make a human connection. Anything that does not make them feel alone with the pain will certainly help out.

Publius said...

JP --

Those people don't need professional emotional support. They need friends and family. If they don't have friends or family, they need professional help in learning how to reconnect with estranged family, or learning how to make friends -- help that takes their situation into account.

Those are legitimate therapeutic goals.

Stuart Schneiderman said...

I agree completely. A therapist should not be a substitute friend,but should help the person reconnect with friends and family or develop new friendships.

NYNM said...

Not only are there different kinds of therapy, there are different goals, and different preferences from the client.

It is a cliche to say that therapy is "rehasing the past" or to retreat to Freudian charactures that died with him in 1939. Well trained therapists know many techniques and use them appropriately. I find it is the non-therapist who continue to discuss "therapy" as a foil to promote why "their" approach is better. We don't need a "mine is better than yours", we need a realistic sense of which approach (coaching, CBT, eclectic, psychodyanamic) would be best for a particular client at a particular time.